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The Breast 20 (2011) 71e77

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The Breast

journal homepage: www.elsevier .com/brst

Original article

The effect of age in the outcome and treatment of older women with ductalcarcinoma in situ

Alice Ho a,*, Anuj Goenka a, Nicole Ishill b, Kimberly Van Zee c, Amanda McLane a,Anne Marie Gonzales a, Lee Tan d, Hiram Cody c, Simon Powell a, Beryl McCormick a

aDepartment of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY, USAbDepartment of Biostatistics and Epidemiology, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY, USAcDepartment of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY, USAdDepartment of Pathology, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY, USA

a r t i c l e i n f o

Article history:Received 7 May 2010Received in revised form21 July 2010Accepted 26 July 2010

Keywords:Ductal carcinomain situRadiotherapyOlder womenWide local excision

* Corresponding author. Tel.: þ1 212 639 6773.E-mail address: hoa1234@mskcc.org (A. Ho).

0960-9776/$ e see front matter � 2010 Published bydoi:10.1016/j.breast.2010.07.005

a b s t r a c t

The effect of increasing age on outcomes and type of treatment given to older women with ductalcarcinoma in situ (DCIS) was assessed. 646 women �60 years old (654 cases) receiving surgery for DCISat Memorial Sloan-Kettering Cancer Center between 2000 and 2007 (8 bilateral) had wide local excision(WLE; 37%), WLE plus radiotherapy (WLEþ RT; 41%), or mastectomy (22%). 45%, 38%, and 16% of patients60e69 years, 70e79 years, and �80 years, respectively, received WLEþ RT (P< 0.001) and 25%, 20%, and13%, received mastectomy, respectively (P< 0.001). Age (P< 0.001), grade (P< 0.001), and necrosis(P< 0.01) were highly associated with treatment. Four-year local recurrence was 3.6%. Overall localrecurrence differed by treatment (mastectomy, 0%; WLE, 5%; WLEþ RT, 4%; P< 0.00001) but not age. It ispossible to identify older women with DCIS in whom the risk of recurrence is acceptably low after WLEalone. WLE alone may be a viable treatment option for select older women with DCIS.

� 2010 Published by Elsevier Ltd.

1. Introduction

Many breast-cancer physicians in the 21st century would agreethat the optimal treatment of ductal carcinoma in situ (DCIS) has yetto be defined. Despite the publication of several randomized stud-ies1e7 over the past decade, two prospective studies8,9 and severallarge retrospective studies10,11 documenting long-term outcomesdata on DCIS patients after various treatments, controversy over themanagement still persists, as exemplified by the wide variation inpractice patterns in DCIS in both Europe and the United States.12e16

Recent epidemiologic data reflect a dramatic increase in thenumber of elderly women with cancer in the United States.17 Thenumber of women �65 years old diagnosed with DCIS in 2010 isprojected to be 25,000 andwill increase by 56% to 39,000 by 2030.18

These changes can be attributed to recent socioeconomic and publichealth trends, such as the enlarging pool of older women,19,20 theprevalenceof breast cancer in olderwomen, and increaseddetectionof DCIS secondary to greater availability and accessibility ofmammographic screening.21 Thus, the necessity of elucidatingtreatment options and better understanding of factors that impact

Elsevier Ltd.

treatment choices becomes even more important in treating olderwomenwith DCIS.

Several retrospective studies have suggested older women withDCIS experience lower rates of local recurrence (LR) than youngerwomen.10,11,22,23 In the 1999 Memorial Sloan-Kettering CancerCenter (MSKCC) analysis of women with DCIS treated with breast-conserving surgery, Van Zee et al. reported lower 6 year actuarial LRrates in older patients independent of histologic subtype, otherpathologic parameters, and the use of postoperative radiotherapy.11

In a study of long-term outcomes after breast-conserving surgeryand radiation for mammographically detected DCIS, Solin et al.demonstrated that age >50 years was independently associatedwith a lower risk of failure.10

The paucity of outcomes and treatment data specific to olderpatients with DCIS, and the lack of uniform consensus amongphysicians on the benefit of radiation after breast-conservingsurgery in all DCIS patients, makes it difficult to determine whetherexcision alone may suffice for elderly women with DCIS. With theexception of one recently published prospective trial of wide exci-sion alone in which the median age of the patients was 60 years,women >60 years were under-represented in the randomizedstudies investigating WLE with or without radiation1e5,24,25 and inanother prospective trial of wide excision alone8,9 in DCIS (Table 1).

Table 1Representation of women �60 Years of Age in Studies of DCIS.

Study Study design Age group(years)

Number ofpatients �60years old

Total numberof patients(all ages)

NSABP B-171e3 RCT �60 294 818EORTC4,5 RCT NR NR 1010SweDCIS6 RCT �65 240 1067

58e64 264UKCCR7 RCT �60e64 447 1701

�65 168Dana-Farber.8 Prospective �60 37 158ECOG.9 Prospective 65e88 241 711Solin et al.10 Retrospective �60 321 1003Van Zee et al.11 Retrospective 40e69 103 171

�70 39

ECOG¼Eastern Cooperative Oncology Group; EORTC¼European Organization forResearch and Treatment of Cancer; NR¼not reported; National Surgical AdjuvantBreast and Bowel Project; RCT¼Randomized controlled trial; SweDCIS¼SwedishDuctal Carcinoma In Situ; UKCCR¼United Kingdom Co-ordinating Committee onCancer Research.

Table 2Patient and tumor characteristics.

Number %

Age (years)60e69 401 62.170e79 191 29.6�80 54 8.4

EthnicityCaucasian 532 82.4Hispanic 32 5.0African-American 57 8.8Other 25 3.9

Laterality at diagnosisRight 316 48.9Left 322 49.8Bilateral 8 1.2

GradeLow 109 16.7Intermediate 312 47.7High 229 35.0Unknown 4 0.6

NecrosisNone 142 21.7Focal 167 25.5Moderate 195 29.8Extensive 97 14.8Unknown 53 8.1

Margin statusNegative 547 83.6Positive 22 3.4Close (<2 mm) 85 13.0

ER statusNegative 25 3.8Positive 66 10.1Unknown 563 86.1

ER¼estrogen receptor.

A. Ho et al. / The Breast 20 (2011) 71e7772

More importantly, outcomes were not analyzed with respect toolder age in these studies.

In this study,we aimed to determine the impact of increasing ageand other clinicopathologic features on treatment patterns andoutcomes in olderwomenwith DCIS treatedwithin a contemporaryeraof surgical and radiation treatments,modernbreast imaging, andrigorous microscopic margin assessment at a single large academiccenter.

2. Materials and methods

Between January 2000 and December 2007, 779 women �60years old underwent surgery for newly diagnosed pure DCIS atMSKCC. After excluding 103 patients with a history of invasivebreast cancer, five with synchronous melanoma skin cancers, and25 with a synchronous contralateral invasive breast cancer, 646patients and 654 cases of DCIS remained.

WLE consisted of complete removal of known tumor. All slideswere evaluated by a team of dedicated breast pathologists forhistologic subtype, the presence of necrosis, nuclear grade, andinvolvement of margins by DCIS. Microscopic size of the DCIS lesionwas not routinely evaluated. SLNB was generally performed in“high-risk” patients in whom there was clinical or radiologicalsuspicion of invasion such as a palpable or mammographic mass,pathology suspicious but not diagnostic for invasion, or extensivedisease requiring mastectomy. The most common reason for SLNBwas multicentric disease requiring mastectomy. Post-excisionmammograms were performed in patients presenting with suspi-cious calcifications and receiving WLE.

Nuclear grade was categorized as low, intermediate, or high,based on the Lagios nuclear grading system.26 Necrosis was definedas the presence of a central zone of necrotic debris with karyor-rhexis, and categorized as minimal, moderate, or extensive. ERreceptor status was not routinely evaluated. Although microscopicmargin evaluation was performed on every case, exact marginwidth and number of ducts involved by DCIS at the margin was notroutinelymeasured. Margins were categorized as negative, close, orpositive. Close margins were defined as the presence of duct(s)involved by DCIS �2 mm from the inked surface of the specimen.

Adjuvant radiationwas deliveredwith two tangential beams. Forthe 127 patients who received radiation at an outside institution,treatment summaries documenting the dose and fraction size wereobtained.A sequential boost to the lumpectomycavitywasdeliveredto 60% (159/264) of patients who received whole breast radiation.No patients received cytotoxic chemotherapy. 17% received

hormonal therapy, consisting of mostly tamoxifen, although letro-zole, anastrozole, and raloxifene were also utilized.

Follow-up consisted of annual mammograms, routine intervalhistory, and physical examinations, commencing from the date ofdefinitive surgery (excision or re-excision) for DCIS. LR was definedas the subsequent occurrence of biopsy-proven invasive or intra-ductal breast cancer in the treated breast and/or regional lymphnodes. Time to LR was calculated from the date of the definitivesurgery to the date of histologically proven recurrence.

The chi-square testwas used to examine differences between thedistribution of characteristics among age and treatment groups. Anordinal logistic regression model was used for multivariate analysisof predictors of treatment received. We reported the odds ratioswith their 95% confidence intervals. KaplaneMeier methods wereutilized to calculate time to local recurrence and overall survival.Univariate associations between clinicopathologic variables andrecurrences were assessed using the log rank test. Multivariateanalysis of recurrence couldnotbeperformeddue to a small numberof events.

3. Results

Table 2 details patient and tumor characteristics of the 646patients. The median age at diagnosis was 67 years (range, 60e88years). Eighty-seven percent of patients presented with mammo-graphically detected disease without a palpable mass. Abnormalmammogram findings included suspicious calcifications in 73%,mass in 12%, and both in 3%. Intermediate- or high-grade DCIStogether represented 83% of lesions. Necrosis was identified in 459(70%) cases, 292 of which were moderate or extensive. Margins

Table 4Clinicopathologic and treatment characteristics by treatment type.

WLE(n¼240)

WLEþ RT(n¼266)

Mastectomy(n¼148)

P value

Number % Number % Number %

Age (years)60e69 120 50% 184 69% 103 70% <0.000170e79 81 34% 73 27% 38 26%�80 39 16% 9 3% 7 5%

EthnicityCaucasian 208 87% 220 83% 111 75% 0.12Hispanic 8 3% 14 5% 10 7%African-American 16 7% 24 9% 17 11%Other 8 3% 8 3% 10 7%

GradeLow 68 28% 28 11% 13 9% <0.0001Intermediate 120 50% 126 47% 66 45%High 50 21% 110 41% 69 47%Unknown 2 1% 2 1% 0 0%

NecrosisNone 82 34% 46 17% 14 9% <0.0001Focal 62 26% 53 20% 52 35%Moderate 52 22% 98 37% 45 30%Extensive 22 9% 51 19% 24 16%Unknown 22 9% 18 7% 13 9%

Margin statusNegative 195 81% 209 79% 142 96% 0.0001Positive 10 4% 11 4% 1 1%Close (<2 mm) 35 15% 46 17% 4 3%Unknown 0 0% 0 0% 1 1%

A. Ho et al. / The Breast 20 (2011) 71e77 73

were negative in 84% of cases, within 2 mm in 13%, and positive in3%. ER status was unknown in 86% of patients, as receptor testingwas not routinely performed. Ten percent of patients were ERpositive and 4% were ER negative.

Treatment characteristics are outlined in Table 3. Of 646 patients,240 (37%) receivedWLEalone, 266 (41%)WLEwith radiation, and148(22%) mastectomy. Eight patients had bilateral DCIS. Approximatelyone-third (32%) of patients underwent axillary lymph-node evalua-tion, either SLNB alone in 192 (29%), SLNB followed by axillarydissection in 16 (2%), or axillary dissection only in 2 (0.3%). Radiationwas delivered to thewhole breast in 265 (41%) patients after breast-conserving surgery. Sixty percent (159/265) of patients receivingwhole breast radiation also received a boost to the lumpectomycavity. Themediandose andnumberof fractionsof patients receivingwhole breast radiation was 5500 cGy (range, 4240e6840 cGy) and28 fractions, respectively. One patient received partial breast radio-therapy to a dose of 3400 cGy. The vastmajority (83%) of patients didnot receive hormonal therapy.

Table 4 represents the clinicopathologic characteristics of all 654cases stratified by treatment type. A significantly higher proportionof patients who received mastectomy were 60e69 years old (70%),compared with those 70e79 and �80 years (26% and 5%,P< 0.0001). Similarly, a significantly higher proportion of patientswho received radiation following WLE were 60e69 years (69%),compared with 70e79 and >80 years (27% and 3%, P< 0.0001). Asthe amount of necrosis increased, so did the proportion of patientsreceiving mastectomy or radiation in addition to WLE (P< 0.0001).Patients with high-grade tumors were also more likely to receivepost-excision radiation or mastectomy (P< 0.0001). Other clinico-pathologic variables stratified by age group are seen in Table 5. Asignificant trendwas seen in the use of radiation andmastectomy inthe 60e69 years age group (45% and 25%) and 70e79 years (38% and20%) age group, compared with the �80 age group (16% and 13%,P< 0.0001). All other examined variables did not correlate signifi-cantly with age.

Table 3Treatment characteristics.

Number %

Treatment typeWLE 240 37%WLEþ RT 266 41%Mastectomy 148 22%

Lymph-node evaluationNot evaluated 444 67.9%SLNB only 192 29.4%AD only 2 0.3%SLNBþAD 16 2.4%

HormonesNo 543 83.0%Yes 111 17.0%

Radiation therapyNo 388 59.3%Yes 266 40.7%

BoostNo 74 11.3%Yes 159 24.3%Unknown 33 5.0%No RT 388 59.3%

Radiation volumesPartial breast 1 0.2%Whole breast 265 40.5%No RT 388 59.3%

AD¼axillary dissection; RT¼radiotherapy; SLNB¼sentinel lymph node biopsy; WLE,wide lesion excision.

In an ordinal logistic regression model, age group (P< 0.001),grade of tumor (P< 0.001), and necrosis (P¼0.01) were found to bestatistically significant predictors of treatment type whencomparing WLE, WLEþ RT, and mastectomy (Table 6). Younger agewas correlated to more aggressive treatment. Similarly, the higher

Table 5Clinicopathologic and treatment characteristics by age group.

60e69 Years(n¼407)

70e79 Years(n¼192)

�80 Years(n¼55)

P value

Number % Number % Number %

EthnicityCaucasian 328 81% 183 85% 48 87% 0.35Hispanic 20 5% 8 4% 4 7%African-American 38 9% 16 8% 3 5%Other 21 5% 5 3% 0 0%

GradeLow 58 14% 42 22% 9 16% 0.28Intermediate 204 50% 84 44% 24 44%High 143 35% 64 33% 22 40%Unknown 2 0% 2 1% 0 0%

NecrosisNone 85 21% 45 23% 12 22% 0.39Focal 95 23% 54 28% 18 33%Moderate 132 32% 52 27% 11 20%Extensive 61 15% 29 15% 7 13%Unknown 34 8% 12 6% 7 13%

Margin statusNegative 351 86% 154 80% 41 75% 0.2Positive 12 3% 8 4% 2 4%Close (�2 mm) 43 11% 30 16% 12 22%Unknown 1 0% 0 0% 0 0%

Treatment typeWLE 120 29% 81 42% 39 71% <0.0001WLEþ RT 184 45% 73 38% 9 16%Mastectomy 103 25% 38 20% 7 13%

RT¼radiotherapy; WLE¼wide local excision.

A. Ho et al. / The Breast 20 (2011) 71e7774

the grade of DCIS and greater the extent of necrosis, the moreaggressive the treatment received. However, when comparing theWLE vsWLEþ RT groups alone, only age and grade were associatedwith the receipt of radiation. The older the age group, the less likelypostoperative radiation was received (P< 0.0001, Table 6). The useof postoperative radiation after WLE was also associated withintermediate- or high-grade tumors (P< 0.0001). Margin statusand necrosis were not found to be statistically significant predictorsof treatment received when only the WLE and WLEþ RT groupswere compared.

Median follow-up was 54 months (range, 6e112 months) for the646 cases. Median follow-up for each treatment group was asfollows: mastectomy, 53 months, WLEþ RT, 52 months, WLE 49months. Four-year overall survival for the entire group was 95.4%(Fig.1a) and4-year local control ratewas 96.4% (Fig.1b),with 31 localrecurrences. Twenty-twoof the local recurrenceswereDCIS andninewere invasive. Differences in 4-year recurrence rates by treatmenttype were statistically significant when all three treatment groups(mastectomy, WLE, and WLEþ RT) were compared (P¼0.005,Fig. 2a). However, there was no statistically significant differencesbetween 4-year recurrence rates when only WLE vs WLEþ RT werecompared (95% and 96%, respectively; P¼0.66, Fig. 2b).

Among the 240 patients who received WLE alone, 16 had localrecurrences (10 DCIS, six invasive) (Fig. 3). Among the 266 patientswho received WLE and radiation, there were 15 local recurrences(12 DCIS, three invasive). None of the 148 patients who receivedmastectomy experienced a recurrence at her last follow-up prior todata analysis. There were 20 LRs (15 DCIS, five invasive) among the401 patients 60e69 years, six LRs (four DCIS, two invasive) amongthe 191 patients 70e79 years, and five LRs (three DCIS, two inva-sive) among the 54 patients �80. Four-year recurrence-freesurvival did not differ by age and was 97%, 98%, and 96%, respec-tively (P¼0.07). Associations between margin status, necrosis, andgrade and the risk of recurrence in patients who received WLE vsWLEþ RT were not statistically significant.

Table 6Multivariate model of predictors of treatment.

Odds ratio (95% CI) P value

All treatment groupsAge (years)60e69 Reference <0.000170e79 0.66 (0.47e0.91)�80 0.17 (0.09e0.32)

GradeLow Reference <0.0001Intermediate 1.77 (1.08e2.88)High 3.41 (1.96e5.94)Unknown 0.80 (0.11e6.03)

NecrosisNone Reference 0.01Minimal/Focal 2.34 (1.45e3.78)Moderate 1.87 (1.15e3.05)Extensive 1.81 (1.01e3.24)Unknown 1.86 (0.98e3.55)

Excluding mastectomy groupAge (years)60e69 Reference <0.000170-79 0.65 (0.43e0.99)�80 0.12 (0.05e0.28)

GradeLow Reference <0.0001Intermediate 2.42 (1.43e4.10)High 5.32 (2.96e9.56)Unknown 1.17 (0.14e9.78)

4. Discussion

Selecting the appropriate treatment for DCIS is a clinical quan-dary that has resulted in substantial variation in both the perceptionof risk and management of the disease among breast-cancerphysicians.27 Although treatments for DCIS do not impact survival,uncertainty in choosing among treatment options is magnified bycompeting comorbidities in older women. Data from multiplerandomized trials1e7 demonstrate a reduction in local recurrencewith the addition of radiation after lumpectomy. However, withoutdata that can reliably identifya groupwhose risk of recurrence is lowenough to justify withholding radiation, many patients, includingelderly women, are often overtreated to achieve the risk reductionseen when adding radiation.

Currently, little is known regarding the clinical, pathologic, andpatient-driven factors that shape treatment decisions in olderwomen with DCIS. The significance of the latter was recentlyhighlighted in a large SEER-Medicare study of 1125 patients(including those>79 years) with DCIS and invasive breast cancer,28

which aimed to determine the role of age and age-related factors insurgical decision-making for breast-cancer treatments. Olderwomen with DCIS were found to choose mastectomy over breast-conserving treatment in DCIS equally compared with youngerwomen, but used less knowledge to decide. Larger tumor size,lower education level, and number of surgeons consulted

Fig. 1. Outcomes for entire cohort: 4-year overall survival¼95.4%, cause-specificsurvival¼100% and 4-year recurrence-free survival¼96.4%.

Fig. 2. a. Local recurrence by WLE�RT or mastectomy. Four-year recurrence-freesurvival: WLE, 95%; WLEþ RT, 96%; mastectomy 100%. b. Local recurrence byWLE� RT. Four-year recurrence-free survival: WLE, 95%; WLEþ RT, 96%.

A. Ho et al. / The Breast 20 (2011) 71e77 75

significantly predicted choosing mastectomy, whereas age, inva-sion, and comorbidities did not.

In our study, age was highly associated with aggressiveness oftreatment. Also, increasing extent of necrosis and grade correlatedwith the addition of radiation to WLE and mastectomies, both of

Fig. 3. Recurrence-free survival by age group. 4Y-RFS: 97% (60e69 years old), 98%(70e79 years old), 96% (>80 years old).

whichwere performedmore frequently in patients 60e69 years oldor with tumors with extensive necrosis or high-grade histology.However, unlike the above SEER registry study, we did not factor inthe impact of comorbidities, in elderly patients, in whom morbid-ities from other co-existing illnesses may transcend the small riskof death due to DCIS and drive treatment choice.

AnLR rateof3.6%at4yearswas reported for the entirepopulation,comparable to 3%e6% 5-year recurrence rates reported in studies ofbreast-conserving surgery with radiation,10,29 and lower than the9%e16% 5-year recurrence rates seen with surgery alone.22,29 Therewas no difference between recurrence rates by age group or bytreatment received. Considering thehighproportion (83%)ofpatientsin the studywhopresentedwitheither intermediate-orhigh-nucleargrade lesions, the low 4-year recurrence rate is encouraging, ashigher-grade tumorsare typically prognostic forearly rather than laterecurrence risk,30 and wewould therefore have expected the bulk oflocal recurrences from higher-grade tumors to manifest themselveswithin the median follow-up period of the study.

The benefit of radiation added to breast-conserving surgery hasbeen clearly documented in a SEER-cohort based study of 3409patients �66 years old with DCIS treated with breast-conservingsurgery, with nearly half the patients receiving postoperative radio-therapy.12 The primary outcome was a second breast-cancer event,including either salvage mastectomy or subsequent breast cancer.High-riskwas defined as the presence of at least one of the followingfeatures: age 66e69 years, tumor size >2.5 cm, comedo histology,and/or high-grade. The addition of radiation to WLE was found tolower the 5-year risk of a second breast-cancer event in both the lowrisk (8% forWLEvs 1% forWLEþ RT, P< 0.001) andhigh-risk (14% forWLE vs 4% for WLEþ RT, P< 0.001) groups.

Several explanations may account for the observed differencesbetween these population-based studies and our results. Amongother well-described risk factors for local recurrence in DCIS such ashistologic subtype, presence of necrosis, grade, and young age,5,31,32

margin status has been described as the most important of themall.33 Patient-specific data on margins and amount of necrosis werenot reported in the SEER study, as this information was not readilyavailable through Medicare claims data and was therefore notfactored into the categorization of low- versus high-risk groups inthe study. Moreover, population-based studies theoretically reflectthe clinical practice patterns in a diverse community setting. It ispossible that there may have been a wide variability in marginevaluation and status, subsequently biasing physicians towardsrecommending radiation in patients with involved margins andthereby overestimating the benefit of radiation.

In contrast, the patients in our study were subjected to thepractice patterns of a single, large academic institution, wheremargin status was regularly evaluated by dedicated breast pathol-ogists and patients were treated by one of a group of 11 breastsurgeons who share relatively compatible treatment philosophieson the significance of obtaining clearmargins inDCIS, as reflected bythe few patients with positive (3%) or close (13%) margins in thestudy and the even distribution of positive or close margins amongthe WLE�RT groups (Table 2). The high percentage of patients withnegative margins in our study may have reduced the observedpotential benefits of radiation. An association between marginstatusand recurrence rates inpatients treatedwithWLE�RTwasnotseen, likely due to the small sample size in each subgroup. Again,secondary to the low total number of events, this study with rela-tively short follow-up lacked the statistical power required to detecta significant benefit conferred by radiation.

Several shortcomings of the study deserve mention. We wereunable to investigate whether re-excision rates influenced treat-ment received. The number of re-excisions performed per patientwas not quantified, but it has been shown thatmultiple re-excisions

A. Ho et al. / The Breast 20 (2011) 71e7776

to obtain clear margins do not appear to negatively impact localrecurrence in DCIS.34 Although the number of re-excisions has beenassociated with the greater likelihood of mastectomy in youngwomen,35 the impact in the older population is largely unknown. Inaddition, neither pathologic size of the tumor nor the extent ofcalcifications correlatingwith theDCIS lesion onmammogramwereroutinely measured at our institution, because quantifying thepathologic size of the DCIS lesion is technically difficult and calcifi-cations seenonmammogramcanunderestimate the truepathologicextentof the lesion. Tumor sizemaynotpredict LR inDCIS, as a linearrelationship was not identified in either the National SurgicalAdjuvant Breast and Bowel Project (NSABP) B-17 or EuropeanOrganization for Research and Treatment of Cancer (EORTC)randomized trials of WLE�RT for DCIS.1,4 Although we wouldanticipate that large tumor size could be a surrogate for extensivedisease requiring mastectomy, it would have been useful to assesswhether tumor size impacted the receipt of radiation after WLE.Lastly, our median follow-up period is short, considering the longnatural history of DCIS.

It is critical to interpret these results within the framework of theinherent biases that accompany this retrospective study. Well-established pathologic risk factors for recurrence such as extensivenecrosis and high-grade tumors were more representative inpatients in theWLEþ RTandmastectomygroups than theWLEalonegroup, which could explain the similarity in short-term outcomesbetween the three treatment groups. Rather than concluding thatpostoperative radiation does not make a difference in this patientpopulation, our studydemonstrates that it is possible for clinicians toselect older womenwith low risk features who dowell in the short-termwithWLE alone. Although the prospect of omitting radiation inthis defined population is appealing, it clearly requires validation inaprospective setting andcollectionof long-termoutcomesdatapriorto acceptance as routine practice.

5. Conclusions

Recent advancements in radiation have afforded more optionsto older patients with DCIS receiving radiation, including theomission of a boost, the use of hypofractionated radiation regimens,and partial breast irradiation, all of which can subsequently reducethe costs, time, and morbidity of adjuvant radiation. A deeperunderstanding of molecular features unique to older women withDCIS36 that are predictive for the development of invasive disease,as well as tools that elucidate the decision-making process of olderwomen with breast cancer, will aid us greatly in the furtherrefinement of our treatment options for this unique population.

Conflict of Interest StatementThe authors have no conflicts of interest.

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